System and method to modulate phrenic nerve to prevent sleep apnea

ABSTRACT

An implantable medical device for treating breathing disorders such as central sleep apnea wherein stimulation is provided to the phrenic nerve through a transvenous lead system with the stimulation beginning after inspiration to extend the duration of a breath and to hold the diaphragm in a contracted condition.

CROSS-REFERENCE TO RELATED CASES

This application is a continuation of U.S. patent application Ser. No.14/715,128, filed May 18, 2015, and titled “System and Method toModulate Phrenic Nerve to Prevent Sleep Apnea,” which is a continuationof U.S. patent application Ser. No. 13/538,713, filed Jun. 29, 2012, andtitled “System and Method to Modulate Phrenic Nerve to Prevent SleepApnea,” now U.S. Pat. No. 10,518,090, which is a continuation of U.S.patent application Ser. No. 11/601,150, filed Nov. 17, 2006, and titled“System and Method to Modulate Phrenic Nerve to Prevent Sleep Apnea,”now U.S. Pat. No. 8,244,359, which claims priority from and the benefitthereof and incorporates entirely: U.S. Provisional Application60/737,808, filed Nov. 18, 2005, and titled “System and Method toModulate Phrenic Nerve to Prevent Sleep Apnea;” U.S. ProvisionalApplication 60/743,062, filed Dec. 21, 2005, and titled “System andMethod to Modulate Phrenic Nerve to Prevent Sleep Apnea;” and U.S.Provisional Application 60/743,326, filed Feb. 21, 2006, and titled“System and Method to Modulate Phrenic Nerve to Prevent Sleep Apnea.”

FIELD OF THE INVENTION

The present invention relates generally to implantable medical devicesand more particularly to a device and method for controlling breathingand for treating Central Sleep Apnea.

BACKGROUND OF THE INVENTION History

Sleep Disordered Breathing (SDB) and particularly Central Sleep Apnea(CSA) is a breathing disorder closely associated with Congestive HeartFailure (CHF). The heart function of patients with heart failure may betreated with various drugs, or implanted cardiac pacemaker devices. Thebreathing function of patients with heart failure may be treated withContinuous Positive Air Pressure (CPAP) devices or Nocturnal NasalOxygen. These respiratory therapies are especially useful during periodsof rest or sleep. Recently, implanted devices to directly addressrespiration disturbances have been proposed. Some proposed therapeuticdevices combine cardiac pacing therapies with phrenic nerve stimulationto control breathing.

Phrenic nerve pacing as a separate and stand alone therapy has beenexplored for paralyzed patients where it is an alternative to forcedmechanical ventilation, and for patients with the most severe cases ofcentral sleep apnea. For example, Ondine's Curse has been treated withphrenic nerve pacemakers since at least the 1970's. In either instance,typically, such phrenic nerve pacemakers place an electrode in contactwith the phrenic nerve and they pace the patient's phrenic nerve at aconstant rate. Such therapy does not permit natural breathing and itoccurs without regard to neural respiratory drive.

Motivation for Therapy

SDB exists in two primary forms. The first is central sleep apnea (CSA)and the second is obstructive sleep apnea (OSA). In OSA the patient'sneural breathing drive remains intact, but the pulmonary airwayscollapse during inspiration, which prevents air flow causing a form ofapnea. Typically, such patients awake or are aroused as a result of theapnea event. The forced airflow of CPAP helps keep the airways openproviding a useful therapy to the OSA patient.

CSA patients also exhibit apnea but from a different cause. These CSApatients have episodes of reduced neural breathing drive for severalseconds before breathing drive returns. The loss of respiratory driveand apnea is due to a dysfunction in the patient's central respiratorycontrol located in the brain. This dysfunction causes the patient'sbreathing pattern to oscillate between too rapid breathing calledhyperventilation and periods of apnea (not breathing). Repeated bouts ofrapid breathing followed by apnea are seen clinically and this form ofdisordered breathing is called Cheyne-Stokes breathing or CSR. Otherpatterns have been seen clinically as well including bouts ofhyperventilation followed by hypopneas only.

In patients with CHF, prognosis is significantly worse when sleep apneais present. A high apnea-hypopnea index (a measure of the number ofbreathing disturbances per hour) has been found to correlate to a poorprognosis for the patient. The swings between hyperventilation and apneacharacterized by central sleep apnea have three main adverseconsequences, namely: large swings in arterial blood gases (oxygen andcarbon dioxide); arousals and shifts to light sleep; and large negativeswings in intrathoracic pressure during hyperventilation. The largeswings in blood gases lead to decreased oxygen flow to the heart,activation of the sympathetic nervous system, endothelial celldysfunction, and pulmonary arteriolar vasoconstriction. Arousalscontribute to increased sympathetic nervous activity, which has beenshown to predict poor survival of patients with heart failure. Negativeintrathoracic pressure, which occurs during the hyperventilation phaseof central apnea, increases the after load and oxygen consumption of theleft ventricle of the heart. It also causes more fluid to be retained inthe patient's lungs. As a result of these effects the patient'scondition deteriorates.

In spite of advances in care and in knowledge there is a large unmetclinical need for patients with sleep disordered breathing especiallythose exhibiting central sleep apnea and congestive heart failure.

SUMMARY OF THE INVENTION

The device of the present invention can sense the patients breathing andit can distinguish inhalation or inspiration from exhalation orexpiration.

The device can periodically stimulate the phrenic nerve as required. Insome embodiments the stimulation may be invoked automatically inresponse to sensed physiologic conditions. In some embodiments thedevice can stop the delivery of therapy in response to sensedconditions. In some embodiments the device can be prescribed anddispensed and the therapy delivered without regard to the sensedconditions. As a result, the device may be used to detect and intervenein order to correct episodes of sleep disordered breathing or the devicemay intervene to prevent episodes of sleep disordered breathing fromoccurring. The methods that are taught here may be used alone to treat apatient or they may be incorporated into a cardiac stimulating devicewhere the respiration therapy is merged with a cardiac therapy. Thetherapy and its integration with cardiac stimulation therapy and thearchitecture for carrying out the therapy are quite flexible and may beimplemented in any of several forms.

Hardware implementation and partitioning for carrying out the methods ofthe invention are also flexible. For example the phrenic nervestimulation may be carried out with a transvenous lead system lodged inone of the cardiophrenic vein a short distance from the heart. One orboth phrenic nerves may be accessed with leads. Either one side or both(right and left) phrenic nerves may be stimulated. Alternatively thephrenic nerve may be accessed through a large vein such as the jugularor the superior vena cava.

Because of the variety of anatomy and branching of the smaller veins,all non-central veins proximate to the phrenic nerve, including thepericardiophrenic, are called “phrenic nerve”. For example, the left orright pericardiophrenic veins are suitable for left or right phrenicnerve stimulation because of their proximity to the phrenic nerves,relatively simple catheter access, relative distance and separation fromthe excitable heart tissue by non-excitable tissue such as thepericardial membrane. Preferred placement of stimulation electrode canbe characterized by: not trigger heart beat when stimulation current isapplied, triggering breath, minimum phrenic nerve stimulation current,and lack of stimulation of different muscle groups not involved inrespiration. As an alternative a stimulation electrode may be place inthe pericardia space on the heart, near the phrenic nerve butelectrically isolated from the heart.

The lead and stimulation electrodes may also take any several forms.Leads may contain anchoring devices to prevent slippage. Multiplestimulation electrodes may be placed along the length of a lead. Anypair of these electrodes may be used for bipolar stimulation. Thestimulator may switch between different electrodes to achieve capture ofthe phrenic nerve at a minimum energy level without stimulating theheart. Any electrode may be used as a sensory electrode, even thoseengaged in intermittent stimulation. Monopolar stimulation may also beused. When the electrode is nonpolar, the reference electrode is likelythe stimulator case. Leads may be coated with medications such as, butnot limited to, steroids.

Implementation of respiration detection and measurement may also takeany of several forms. Transthoracic impedance measurement may be takenfrom electrodes implanted at locations in the body to measure or sensethe change in lung volume associated with breathing. Alternatively oneor more implanted pressure transducers in or near the pleural cavity maybe used to track pressure changes associated with breathing.Alternatively, respiration sensing may be carried out by an airflowsensor, a respiratory belt, a temperature sensor, a humidity sensor,and/or a CO2 sensor. In conjunction, or in alternative, sensingelectrodes may be used to sense events such as cardia electricalavidity, patient activity, and patient metabolic state. Knowledge ofbreathing rates and patterns are useful in carrying out the inventionbut distinguishing reliably the inspiration phase from expiration phaseis a breath is particularly important for timing the delivery of thestimulation.

Any detection system used to trigger stimulation has a disadvantage ofbeing susceptible to non-respiratory signals such as an artifact ofmotion, sudden arousal, or cough. The recognition of possible artifactsand comparison to stored breath history of normal breath patterns may beadvantageous. If a given breathing pattern significantly differs fromthe template then the breath may be rejected and stimulation deferred.Artifacts may be recognized and rejected by identification of: anunacceptably fast inhalation slope, an unacceptably high amplitude oftidal volume and/or the presence of a high frequency component in therespiratory signal spectrum. In all cases the stimulator logic mayreject this “breath” and not apply a stimulation burst. It may also beuseful to reject signals for some duration immediately following astimulation pulse. This so-called “refractory period” may be measured asthe duration of stimulation plus minimum time of expiration. Inaddition, an implantable stimulator may be equipped with anaccelerometer. Acceleration signals may be used to reject breath orseveral breaths and delay stimulation. After a normal pattern ofbreathing is restored, stimulation is resumed.

We consider that breathing has an inspiration phase followed by anexpiration phase. Each breath is followed by a pause when the lungs are“still” before the next breath's inspiration. The device deliversphrenic nerve stimulation after the start of inspiration preferablytoward the start of exhalation. The duration and magnitude of thestimulation is selected to “extend” the expiration phase or therespiratory pause of a naturally initiated breath. We note relativelylittle change in lung volume and little air exchange during thestimulation phase of the therapy. We have observed that prolongation ofa natural breath, while keeping some air trapped in the lungs, delaysthe inspiration phase of next natural breath until the air trapped inthe lungs is exhaled. For this reason our therapy has a tendency tolower the observed breathing rate. Typically the stimulation maintainsactivation of the diaphragm long enough to mimic a patient holding theirbreath by not letting the diaphragm relax. This mechanism of actioncontrols the rate of breathing by increasing the effective duration ofeach breath.

Our experimental animal work has demonstrated the ability of thestimulation regime to down-regulate breathing rate (and minuteventilation) to a desired (preset) value while maintaining naturalinspiration (i.e. by prolonging exhalation and extending the respiratorypause phases of the breath) without blocking the phrenic nerve. Webelieve that maintenance of natural inspiration is important since itallows prevention of airway collapse and retains certain capacity of thebody to auto regulate rate of inspiration and depth of breathing. Wealso demonstrated that unilateral and transvenous stimulation issufficient to carry out the invention and insures adequate levels ofpatient safety. In the process of prolonging the respiratory pause we“stilled” the lungs (no air movement occurred) while keeping one lunginflated. We believe that the mechanism of action for this observedeffect is a physiologic feedback that prevents the respiration controlcenter of the central nervous system from initiating the followingbreath. In other words we have invented a novel and practical therapy bysubstantially immobilizing at least one lung of the patient bymaintaining the diaphragm in the contracted state by transvenouselectrical stimulation of a phrenic nerve for the duration sufficient tosubstantially reduce breathing rate and alter the blood gas compositionof the patient.

BRIEF DESCRIPTION OF THE DRAWINGS

A preferred embodiment and best mode of the invention is illustrated inthe attached drawings where identical reference numerals indicateidentical structure throughout the figures and where multiple instancesof a reference numeral in a figure show the identical structure atanother location to improve the clarity of the figures, and where:

FIG. 1 is a schematic diagram of a device implanted into a chest cavityconfigured to prevent sleep apnea;

FIG. 2 is another schematic diagram of a device implanted into a chestcavity configured to prevent sleep apnea;

FIG. 3 is a flow diagram of the device configured to supply pulses toprevent sleep apnea;

FIG. 4 is a flow diagram of the device configured to shape pulses toinnervate a phrenic nerve to prevent sleep apnea;

FIG. 5A is a diagram showing experimentally derived physiologic datadisplayed in a panel;

FIG. 5B is a diagram showing experimentally derived physiologic datadisplayed in a panel;

FIG. 6 is a schematic diagram showing physiologic data known in theprior art; and

FIG. 7 is a schematic diagram showing physiologic data and device timinginformation.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 is schematic diagram showing an implanted medical device (IMD)101 implanted in a patient's chest for carrying out a therapeuticstimulation of respiration. The patient has lungs shown in bold outlineand indicated at 102 overlying the heart 103. The right phrenic nerve104 passes from the head alongside the heart to innervate the diaphragm106 at location 105.

In this embodiment a transvenous lead 107 passes from the IMD 101 andpasses through venous vasculature to enter the cardiophrenic vein 108 onthe right side of the patient. The cardiophrenic vein 108 lies next tothe phrenic nerve 104 along the heart. Electrical stimulation pulsessupplied to the stimulation electrode 110 on lead 107 interact with thephrenic nerve to stimulate it and thus activate the diaphragm 106. Inthe figure a series of concentric circles 112 indicate electricalstimulation of the phrenic nerve. In this embodiment the stimulationelectrode 110 lies far enough away from the heart 103 to avoidstimulating the heart 103. In this embodiment only one branch of thephrenic nerve 104 is stimulated and the other side of nerve is undernormal physiologic control.

A respiration electrode 114 on lead 107 cooperates with an indifferentelectrode on the can of the IMD 101 to source and sink low amplitudeelectrical pulses that are used to track changes in lung volume overtime. This well known impedance plethysmography technique is used toderive the inspiration and expiration events of an individual breath andmay be used to track breathing rate. This impedance measurement processis indicated in the diagram by the dotted line 116 radiating from theelectrode site of respiration electrode 114 to the IMD 101.

Transvenous stimulation of the phrenic nerve from a single lead carryingan impedance measuring respiration electrode is a useful system since itpermits minimally invasive implantation of the system. However otherarchitectures are permissible and desirable in some instances.

FIG. 2 is a schematic diagram showing alternative electrode and leadplacements for use in carrying out the stimulation regime of theinvention. In some patients it may be easier or more suitable to accessthe phrenic nerve in the neck in the jugular vein at electrode location200. In some instances it may be preferable to place electrodes in veinsboth near the right phrenic nerve as indicated by the deep location of astimulation electrode 110 and in the left phrenic nerve at electrodelocation 202. Other potential locations for the stimulation electrodesare the large vessel (SVC) above the heart indicated by electrode 203.Unilateral stimulation is preferred but having multiple sites availablemay be used to reduce nerve fatigue. Non-venous placement is possible aswell. For example, placement of a patch electrode in the pericardialspace between the heart and within the pericardial sac is suitable aswell, as indicated by electrode location 205. In this embodiment theinsulating patch 206 isolates spaced electrodes 207 and electrode 208from the heart. The lead 204 connects this bipolar pair of electrodes tothe IMD 101.

Also seen in this figure is a pressure transducer 209 located in thepleural cavity and connected to the IMD 101 via a lead. The pressuretransducer 209 tracks pressure changes associated with breathing andprovides this data to the implanted device 101. The pressure transduceris an alternative to the impedance measurement system for detectingrespiration. Such intrapleural pressure signal transducers are known inthe respiration monitoring field.

FIG. 3 shows a schematic diagram of a system for carrying out theinvention. The system has an implanted portion 300 and an externalprogrammer portion 301.

The IMD 101 can provide stimulation pulses to the stimulation electrode110. A companion indifferent electrode 306 may be used to sink or sourcethe stimulation current generated in analog circuits 303. A portion ofthe exterior surface 302 of the IMD 101 may be used with respirationelectrode 114 to form an impedance plethysmograph. In operation, logic305 will command the issuance of a train of pulses to the respirationelectrode 114 and measure the amplitude of the signal as a function oftime in circuits 304. This well-known process can measure therespiration of the patient and find the inspiration phase and theexpiration phase of a breath. Respiration data collected over minutesand hours can be logged, transmitted, and/or used to direct the therapy.

When the therapy is invoked by being turned on by the programmer 301 orin response to high rate breathing above an intervention set point, thelogic 305 commands the stimulation the phrenic nerve via the stimulationelectrode 110 at a time after the beginning of the inspiration phase.Preferably the stimulation begins after the onset of exhalation. Thereis some flexibility in onset of stimulation. The shape of thestimulation pulses is under study and it may be beneficial to have thelogic 305 command stimulation at higher amplitudes of energy levels asthe stimulation progresses. It may also be desirable to have stimulationramp up and ramp down during the therapy. It may prove desirable tostimulate episodically. The therapy may be best administered to everyother breath or in a random pattern. The programmer may permit thepatient to regulate the therapy as well. However in each case thestimulation of the diaphragm “stills” the diaphragm resulting in anamount of air trapped in at least one lung and extends the breathduration.

The duration of the stimulation is under the control of logic 305. It isexpected that the therapy will be dispensed with a fixed duration ofpulses corresponding to breathing rate. It should be clear that otherstrategies for setting the duration of stimulation are within the scopeof the invention. For example the breathing rate data can be used to setthe stimulation duration to reduce breathing rate to a fraction of theobserved rate. The therapy may also be invoked in response to detectedhigh rate breathing or turned on at a fixed time of day. In a devicewhere activity sensors are available the device may deliver therapy attimes of relative inactivity (resting or sleeping). Activity sensors mayalso help in the detection and rejection of artifacts. An accelerometer,such as those used in cardiac pacing, would be an exemplary activitysensor.

FIG. 4 shows a schematic diagram of an alternate partitioning of thesystem. In this implementation, the respiration sensing is carried outoutside the patient with sensor 404, while the implanted portion 400communicates in real time with an external controller 401 via coils 403and 402. This respiration sensor 404 may be a conventional respirationbelt or thermistor based system. Real time breathing data is parsed inthe controller 401 and control signal sent to the IPG 101 to drivestimulation of the phrenic nerve via lead 107. This implementationsimplifies IMD 101 portion for the system and may be useful for deliveryof therapy to a resting or sleeping patient.

FIG. 5A and FIG. 5B is set forth as two panels. The data collected froman experimental animal (pig) is presented in the two panels and shouldbe considered together. Panel in FIG. 5B plots airflow into and out ofthe animal against time, while panel in FIG. 5A plots volume againsttime. In the experiment the volume data was computed (integrated) fromthe airflow measurement. The two panels are two ways of looking at thesame data collected at the same time. In each panel the dotted tracing500 in FIG. 5B and 502 in panel FIG. 5A represent the normal or naturalor not-stimulated and therefore underlying breathing pattern of theanimal. In panel FIG. 5A the inspiration phase of tracing 502 is seen assegment 514. After tracing 502 peaks, the expiration phase begins asindicated by segment 516. The figure shows that along trace 502, the airthat is inhaled is exhaled before 2 seconds has elapsed, as indicated bythe dotted trace 502 returning to the zero volume level.

Trace 504 is associated with the unilateral delivery of stimulation 508to a phrenic nerve. In the tracing the start of stimulation at time 518is well after the start of inspiration and corresponds approximately tothe reversal of airflow from inspiration to expiration as seen at time518. Very shortly after the stimulation begins the animal inhales moreair seen by the “bump” 520 in the tracing 504 in panel FIG. 5B. A smallincrement in the total volume corresponding to this bump is seen at thesame time in panel FIG. 5A. Of particular interest is the relativelyflat tracing 522 corresponding to no significant change in lung volumeduring stimulation. Once stimulation terminates the lungs expel air asseen at volume change 524 in panel FIG. 5A corresponding to outflowlabeled 512 in panel FIG. 5B. Only after the exhalation outflow 512 wascomplete did the sedated experimental animal initiate the next breath(not 30 shown). Thus duration of breath was extended in this case fromapproximately 2 seconds to approximately 6 seconds resulting in thebreathing rate reduction from 30 to 10 breaths per minute. The datasupport the assertion that adequate phrenic stimulation initiated afterinspiration and during expiration can “prolong” or “hold” the breath andthus regulate or regularize breathing which it the value of theinvention.

FIG. 6 shows about 601 of rapid breathing 603 followed by or preceded byapnea 602 events. This waveform is a presentation of Cheyne-Stokesrespiration (CSR) well known in the prior art. The corresponding tracingof blood gas 607 indicates that the rapid breathing drives off bloodcarbon dioxide (CO2) as indicated the slope of line 606. CSR begins withthe rise of CO2 as indicated by ramp line 605 which triggers the rapidbreathing. The ventilation drives the CO2 too low resulting in a loss ofrespiratory drive and an apnea event 602. During the apnea the level ofCO2 rises as indicated by the slope of line 604. Once a threshold isreached the cycle repeats.

FIG. 7 shows a schematic diagram showing the delivery of the inventivetherapy in the context of a patient experiencing CSR respiration. Thepatient experiences several quick breaths 701 and then the device isturned on as indicated by the stimulation pulses 709. The device looksfor a natural inspiration and waits until about the turn frominspiration to expiration, then the burst 709 of stimulation isdelivered to a phrenic nerve. As explained in connection with FIG. 5 thestimulation delays breath 706. This next breath is also a candidate forthe therapy and stimulation burst 710 is delivered to the phrenic nervedelaying breath 707. In a similar fashion the device intervenes inbreaths 707 and 708. It is expected that the lower rate breathingresulting from repeated application of the therapy will keep the CO2level in a “normal” range 715 and prevent CSR. The therapy could also beinvoked in response to a detected bout of CSR but this is not necessaryand it is believed that keeping a patient out of CSR is the bettertherapy.

It may be noted that the stimulation waveforms vary in FIG. 7 withstimulation 710 rising in amplitude while stimulation 711 decreases inamplitude. Note as well that stimulation 712 ramps up and then downduring the therapy. It is expected that the best waveform may vary frompatient to patient or may vary over time. Also seen in the figure is arefractory period typified by period 730 that may be implemented in thelogic 302 to prevent the device from issuing the therapy too dose intime to the last intervention. In general the refractory periodeffectively disables the delivery of therapy until the refractory periodexpires. This places an effective low rate on stimulated rate ofbreathing. The refractory may be fixed, programmable or adjusted basedon sensed breathing rate.

1-10. (canceled)
 11. A medical device for use in a patient comprising: atransvenous stimulation lead, the stimulation lead including at leastone stimulation electrode configured to be placed in a vein adjacent toat least one phrenic nerve of the patient; an implanted medical device(IMD) configured to be implanted in a body of the patient, the IMDconfigured to be electrically connected to the at least one stimulationelectrode; a respiration sensor configured to provide a respirationsignal to the IMD; and control logic incorporated within the IMD, thecontrol logic configured to analyze the respiration signal and deliverstimulation pulses to maintain activation of at least a portion of adiaphragm of the patient the stimulation pulses being selected from agroup including consistent amplitude stimulation pulses, progressivelyincreasing amplitude stimulation pulses, progressively decreasingamplitude stimulation pulses, and pulses in which an amplitude of thestimulation pulses increases and then decreases.
 12. The medical deviceof claim 11 wherein the control logic is further configured to deliverthe stimulation pulses at a time proximate a transition from aninhalation phase of respiration to an exhalation phase of respiration.13. The medical device of claim 12 wherein the control logic is furtherconfigured to analyze the respiration and deliver the stimulation pulsesat an end of natural inspiration.
 14. The medical device of claim 12wherein the control logic is further configured to analyze therespiration and deliver the stimulation pulses for a duration thatexceeds natural exhalation.
 15. The medical device of claim 12 whereinthe control logic is further configured to analyze the respiration anddeliver the stimulation pulses at an end of natural inspiration and fora duration that exceeds natural exhalation.
 16. The medical device ofclaim 11 further comprising at least one sensing electrode in electricalcommunication with said IMD, the sensing electrode being capable ofsensing cardiac electrical activity and transthoracic impedance.
 17. Themedical device of claim 11 further comprising an implantable motionsensor capable of sensing motion of the patient, wherein the controllogic is capable of sensing and analyzing motion signals.
 18. Themedical device of claim 17 wherein the control logic is furtherconfigured to deliver phrenic nerve stimulation based on the respirationsensor and to disable phrenic nerve stimulation based on the motionsensor.
 19. The medical device of claim 17 wherein the motion sensor isan accelerometer.
 20. The medical device of claim 17 wherein the controllogic is configured to reject respiration signals indicative of cough,arousal, or movement.
 21. The medical device of claim 11 wherein thecontrol logic is configured to reject respiration signals that appearduring a refractory period that follows a stimulation pulse.
 22. Themedical device of claim 11 wherein the stimulation lead includes aplurality of stimulation electrodes.
 23. The medical device of claim 22wherein stimulation provided by the plurality of stimulation electrodesis bipolar.
 24. The medical device of claim 11 wherein stimulationprovided by the at least one stimulation electrode is monopolar.
 25. Themedical device of claim 11 wherein the stimulation lead has at least oneanchoring mechanism.
 26. The medical device of claim 11 where the atleast one stimulation electrode is coated with medication.
 27. Themedical device of claim 11 wherein the respiration sensor is configuredto be implanted in the body of the patient.
 28. The medical device ofclaim 27 wherein the respiration sensor includes a transthoracicimpedance sensor or a pressure transducer.
 29. The medical device ofclaim 11 wherein the respiration sensor is configured to be disposedoutside the body of the patient.
 30. The medical device of claim 29wherein the respiration sensor includes a respiration belt or athermistor-based system.
 31. The medical device of claim 11 wherein thecontrol logic is configured to calculate an observed breathing ratebased on data from the respiration sensor and to deliver the stimulationpulses at a fixed stimulation rate that is less than the observedbreathing rate.
 32. The medical device of claim 11 wherein thestimulation lead is configured to be retained in a pericardiophrenicvein.
 33. The medical device of claim 11 wherein the stimulation lead isconfigured to be retained in a brachiocephalic vein.